653 Septic Inspection 2002 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONME
DEPARTMENT OF ENVIRONMENTA
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 6' '' /*-� Si%r' a/97,/ciet, .Q,0
Owner's Name: /2 .yi/G'UD Gt'42 /7
Owner's Address: P / O "/J 1"
Date of Inspection: X/ s-/3."7/t, Z S 3/_ 0 a
Name of Inspector: (please print) /C_ - #9 a i /L-j i7�
Company Name: , ¶Y4JtC�/ /C IL/9/..t—to—to
Mailing Address: [/ 1c't;/-f/7,/ „co, /
t5 &c .f+17955
Telephone Number: /—S//,� 532 C9 ',--
CERTIFICATION STATEMENT 1703 39X ,$3/S j
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.310 of Title 5(310 CMR 15.000). The system:
NOErsAMPION BOARD OF HEALTH
"f_-/e7.7-/%/'s-e /J/ d
i'/c /F UAL
/zf. et lSrl%t2
/64 Ai fT 4,741y4
✓ Passes
Conditionally Passes
Needs Further Ev ujtion by)he Local Approving Authority
Fails
Inspector's Signature: / .4..1CO Date: L/1/4 i7
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of H
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,0.
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments S%f 6/>7 .5 /'Li ?ci i ye? c- 1/
/L/Pr< / Tao S /.y /not-/ht /tcrc ec/
L ec-c/ yr. / 0sys C.y/ fjat: 4/e. 0
/X.? 'tic) ,f .e.77 /s/ C/Lei G441/J'
""'This report only describes conditions St the timed(inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A
CERTIFICATION(coined)
// m- /`7�i At/ ,f
Property Address: 60P 5 Ip.j3
Owner:
/LI r
w - 4a
Date of Inspection: v$ ' J —0 7
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15304 exist.Any failure criteria not evaluated are indicated below.
.-&e 2 fnCs ,e�.e_o cl r eS
/20,40 ro
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is Imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
for the following statements.If"not determined"please
ND explain:
Observation of sewage backup or break out or bigb static water level m the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
_ broken pd 1e(s)se replaced
obstruction is removed
distribution bolt is lever es emplaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Meths
_broken pipe(s)are replaced
obstruction is removed
ND explain:
VDU A'A
q ■
at RIEntltn
.�
no not..n
,v.
Page 3 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4 c5J ace $/0140.0-7 ,AY0 /eat
a 1-1 dor
Owner: p 1211
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b)that the
system 'snot functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,If any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more froth a
private water supply well**. Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
fi TS'
5,
0,4.s:ins:it:Ai
No 3o147
Page 4 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: _ lt"3• . /CCL/ 5 / ��•oafs " 'cam , cv,
il.V/Ih�r/a /)/O,tJ MJ,7
Owner: t1), is t/I/ ,
Date of Inspection: 73./,/O a
D. System Failure Criteria applicable to all systems:
You must indicate"yes'or"no'to each of the following for all inspections:
Yes No
_ _ • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
/Uischarge or pending of effluent to the surface of the ground or surface waters due to an overloaded or
- . clogged SAS or cesspool
/%41 Static-Static liquid level in the distribution hew. above outlet invert due to an overloaded ar clogged SAS or
cessponl
/(?A/'J Liquid depth in cesspool is less than b"below invert or available volume is less than''day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped Nsn
/ k" Any portion of the SAS.cesspool or privy is below high ground water elevation.
V Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
y_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
7�F{ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis.
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.[
(YesMo)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15 101.therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: (-74--441
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either yes or no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or arts
"yes"in Section D above the large system has failed.The owner or operator of any large system considered
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 31'
15.304.The system owner should contact the appropriate regional office of the Department.
Page .5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
> /CHHECKLIST
Property Address: o/"3J l'��'4' -1 tin •z V ic-' r �cil
///7/ V/.ail.7./.2 yc r..-I ,t 2/7
Owner: r ' ,t)/) U
Cy-
Date of Inspection:
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
__ Pumping information was provided by the owner.occupant,or Board of Health
✓Weir any of for system components pumped out in the pt evions two weeks''
✓ lias the system received normal flows in the previous two week period'?
✓ Have large volumes of water been introduced to the system recently or as pail of this inspection?
n ce e as built 9C> e F'
�k'T /� Wer tans of the system obtained and examined?Of they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage hack up?
�/_ Was the site inspected for signs of break out ?
1, Were all system components.excluding the SAS, located on site
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the-baffles af or tees, material of construction, dimensions,depth of liquid. depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
Yes no
The size and location of the Soil Absorption System (SAS)on the site has been determined based on'.
Existing information. For example,a plan at the Board of Health. /fJo T /°C--' A/c A2 c'4'
Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)1310 CMR I 5.302(3)(b)]
Page (,of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propery Address:
!r 63 It-Ce 5"i 4,J, 1,' ,/,--,,,-- At'Q
/U[JC 7 1 hC7 39-1,AoJ �,ll A-,/}
Owner: / A . L,�!/;l/' / `
Date of Inspection: 'S/J' / O L
PLOW CONDITIONS
RESIDENTIAL 3 Number of bedrooms(design): ✓ Number of bedrooms(actual): 3 -'
F //!1 3 j J
DESIGN flow based on 310 CMR 15.203(for example: 110 god x #of bedrooms):i-___
Number of current residents: /
Does residence have a garbage grinder(yes or no):
if yes separate inspection required) �-t-r %//° � �`�`
Is laundry system a separate sewage system (yes or no):�O I D P / �� e t
Laundry aV4em inspected (yes or no)'. Ll 0 3 r
's 1 Seasonal use(yes or no) Ale-, 7 //41 .t!/4-
Wmer meter readings. if available(last 2 years usage(gild)) /%4.v
Sump pump(yes or not _ac/C)
Last date of occupancy: -
COMMERCIAUINDIISTRIALO/3-24
Type of establishment:
Design flow(based on 310 CMR 15.203): _. . gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or nn): __.
Water meter readings. if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information'. obi-wet's QJ--(e�/�7� /
Was system pumped as part of the inspection(yes or no): / ' -$ q //A–P[��
If yes, volume pumped/40C gallons-- How was qufntity pumped determined? /f
Reason for pumping: 14../SS e G /"7 d Ai
TYPE OF SYSTEM —
t/Septic tank,distribution box,soil absorption system af%O D/ 57 AO
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): PO
'Page 7 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: --3
L'f etas 4 � Air%
Owner:
Date of Inspection:
�3�/O 1
J it F/� /
--��-0L 1.'.7r /71J(rye•t-7 ,rc 9N
BUILDING SEWER(locate on site plan)
Depth below grade: s3
Materials of consintctinn- cast iron k40 PVC other(explain) _
Distance from private water supple well or suction line'
•Comments(on condi(ion ofjoin K, venting, evidence of leakage. _O ��-
L2/J /C. /4o - - R ._etc):
SEPTIC/TANK:_(locate on site plan)
• Depth below grade: /2 c
Material of construction:_(concrete metal fiberglass
other(explain)
(.z If tank is metal list age: = Is age confirmed b)-a Cenificate _____ fiance of certificate)
Dimensions: CS A 9 r`j y wo- (yes or no):_ (attach a copy of
Sludge depth: - --- A9-e-)0 ./H ('3.
/Z —.
Distance from top of sludge to bottom of outlet tee or baffle: /.2
is ness: •• -'_-_-
Scum thickness:
Distance from lop of scum to top of outlet tee or baffle.
Distance from bottom of scum to bottom of outlet tee or baffle: - .O
How were dimensions determined.
Comments(on pumping recommendations,
as related to outlet invert,evidence inlet and outlet lee or baffle c ondition thuctural inte
of leaee, etc.): ¢rite, liquid levels
/La
n'7 e C C �- � Ci, -_---
-
'GREASE TRAP: (locate
on site plan)
Depth below grade:
Material of construction: concrete metal— fiberglass_
(explain): __concrete_
Dimensions: _ ---- '---
Scum thickness: _-- -- - __
Distance from top of scum to top of outlet tee or baffle:__
Distance from bottom of scum to bottom of outlet tee or ba07e:
Date of last pumping:
as related to outlet invert, evidence of leakage,(on pumping recommendations,P B inlet and outlet tee or baffle condition,structural integrity, liquid levels
ge, etc.):
polyethylene other
Page R of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ProPedy Address: iL,4P57/ I / , 1 )/i�J % </
rC T7L9ll.3/24/,t./ ft 71
Owner: -- S /,j//(��� / • (I//(/1 /)
Date of Inspection: % �.
TIGHT or HOLDING TANK: _(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade
J2/(1/9
Material of construction: _ concrete__..metal fiberglass _polyethylene other(explain):
Dimensions'
Capacity. _ gallons
Design Plow- gallons/de%
Alarm present(yes or no)
Alarm level. Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches.etc.).
DA/.5'
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
N[7 1,1 7-- ee(f
Depth of liquid level above outlet invert:
Comments(note if hox is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box.etc)_
PUMP CHAMBER: (locate on site plan)
pN /9
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.)
Page rt of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 615 /•GC'544-7/7./%1/4/4 ✓21
/f/O Zi/JS/7/77 if w t I/-7
Owner:
Date of Inspection: r"i-/ // ;cam
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain wit)'.
Type / 7 e./ (/ /( ce
leaching pits number _
leaching chambers. mmihet t / //- i // 1' /4 7 r /
leaching galleries, number. _ /- /"/- /� C TJ4sF' 7,i�//J i'71 / '3
leaching trenches. number, length: _..__. _. ...
leaching fields.number,dimensions:
overflow cesspool,number: __
innovative/alternative system Type/name of technology:
Comments(note condition of soil. signs of hydraulic failure, level ofponding. damp soil,condition of vegetation,
etc ):
/)7v/9
CFSSPOOLS: (cesspool must he pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert. _
Depth of solids layer
Depth of scum lacer.
Dimensions of cesspool.
Materials of construction: _
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level ofponding.condition of vegetation.etc.)
ocPRIVY: on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc):
Page 10 of 11
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
x ,5 3 - (<1P S i//70 i"2/s' /1t'( �j
Property Address: [ / 1 '4
Owner: % c /7 Zc'4!/J !C NA' 4)
Date of Inspection: l) The/ O Z
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the huilding.
La/1/ t to co/1/
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7;>
6 ,,-Al(01: Af r
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s CJ '
/000 //(t.E',Sr' Y7C
/792/ a
I
-ei9C/7 //72 /7/ 1`
/OO ft.' /J
75" e ,479
1. )
Page I I of I I
OFFICIAL, INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 6J3 j.L cif$ ii/�/-'?r/-) /Y'/C/ '/1) ,c)r,y
Owner: /c=BS/I ,1,7 /Up UIl7/1 /)
Date of Inspection: s/ j/ /O Z
SITE EXAM j
Slope
Surface water AA's ch
Check cellar Q/2 ,(JCl 7 U'''ay'/)e " 2, J
Shallow wells A A/ n
Estimated depth to ground water /_. feet
Please indicate(check)all nrethuds used to determine Ile high ground water elevation:
'v A Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
_.-_Checked with local Board of Health-explain:
✓ Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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